Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0009, written 7 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jan 2025 |
|---|---|
| Reference | 2025-0009 |
| Deceased | Sheila Nicholls |
| Coroner | Michael Walsh |
| Coroner area | Buckinghamshire |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
THE BEACONSFIELD CORONER’S COURT IN THE MATTER OF AN INQUEST TOUCHING THE DEATH OF SHEILA ANN NICHOLLS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Mandeville Grange Nursing Home 1 CORONER I am Michael Walsh, HM Assistant Coroner, for the coroner area of Buckinghamshire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. https://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 https://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST The inquest into the death of Ms Sheila Ann Nicholls, aged 80, was opened on 22nd November 2023. The investigation concluded at the end of the inquest on 23rd October 2024. The medical cause of death was: Ia Hypoxia Ib Food Bolus Obstruction of Upper Airway II Severe Ischaemic Heart Disease (Stented) The Narrative conclusion to the inquest was: Sheila choked on food during a short period of respite care, at Mandeville Grange Nursing Home on 19.11.2023. Information on Sheila’s swallowing problem was provided to the nursing home staff by family members, but the nursing home’s assessments and checklists and handovers either omitted or did not share that information or the risk it presented, with all relevant staff. Breakfast was therefore given to Sheila that did not take her swallowing problem into account. Sheila subsequently choked on toast, suffering hypoxia that led to a cardiac arrest and what was an otherwise avoidable death. Neglect contributed to the cause of death. 4 CIRCUMSTANCES OF THE DEATH Sheila died due to choking on food only a day after entering the nursing home on 18.11.2023 as a respite care resident. Her family warned the nursing home of Sheila’s swallowing difficulties and a need for monitoring whilst eating and to avoid certain foods, but important information went unrecorded and was not shared between staff, resulting in Sheila being provided with food she should not have been given and/or should have been prepared differently. 1 On 19.11.2023 Sheila was given breakfast on which she choked, requiring emergency assistance from staff, only one of whom had valid current life support training, and the emergency response included ineffective CPR. Sheila died from choking on the food provided. CORONER’S CONCERNS 5 During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Concerns directed to Mandeville Grange Nursing Home CONCERNS Management and circulation of internal written policies: 1. Mandeville Grange Nursing Home considered several existing policies required improvement, and so they were rewritten following Sheila’s death, some using template documents from a health and safety outsourcing website. However, some rewritten policies still included clauses that remained irrelevant to the nursing home (e.g. regarding ‘oral suction devices’), and several policies remained undated and unsigned, and it was therefore far from clear which policies had been ratified and were in force; with poor version control overall. It was not always clear when policies had been written or by whom; when and by whom they had been reviewed; and if and when they were circulated, and to which staff members. It was also unclear from the evidence of staff members, whether policies were properly embedded and/or understood, and/or had been read by all staff, as there were no checklists confirming staff had read and understood the policies. At the time of the inquest, staff training on new policies was said to be ongoing, and planned staff competency assessments had yet to be arranged. Deficient management of internal policies creates a risk of death to future residents where there is an inability to verify and record that all policies: (a) are relevant to Mandeville Grange in the first instance; (b) have been ratified and are in force; (c) have been reviewed as required; and (d) have been circulated to all relevant staff, with confirmation of those policies having been read and understood. Training in emergency response: 2. At the time of Sheila’s death, of the several staff members that responded to her choking emergency, only one staff member (nurse GC) had currently valid training in life support, but still undertook CPR ineffectively without being corrected by other staff. Evidence was also given that no simulated emergency drills were ever performed, and some staff were never aware their training had expired. Whilst nurse GC still works for Grange Mandeville Nursing Home, it is unclear how that nurse will be supported in their ability to provide an adequate emergency response, bearing in mind their existing training appears to have been insufficient. The deficiency in training and embedding that training, both generally for all staff, and for that specific nurse, creates a risk of death to residents should future emergencies arise. Investigating and learning from adverse incidents: 2 3. Evidence was given of two internal investigations undertaken by Mandeville Grange management following Sheila’s death, both of which failed to adequately consider significant matters. The investigations were performed by staff untrained in investigating adverse incidents. The inability to adequately investigate such matters creates a risk of death to future residents given deficiencies in care may not be identified or remedied in a timely manner. At the time of the inquest, the nursing home’s expressed intention was to instruct an external person or organisation to investigate future unexpected or unnatural deaths. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action in relation to the concerns above. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5th March 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. Sheila’s son 2. Sheila’s daughter 3. Mandeville Grange Nursing Home 4. 5. , former clinical lead nurse at Mandeville Grange Nursing Home , RGN, at Mandeville Grange Nursing Home I have also sent it to: the Care Quality Commission, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 7th January 2025 Michael Walsh HM Assistant Coroner Beaconsfield Coroner’s Court 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
FAO Mr Michael Walsh HM Assistant Coroner c/o Ms Margaret Mullin, Coroner’s Officer By Email: Dear Sir 5 March 2025 Inquest touching the death of Ms Sheila Ann Nicholls Response to Regulation 28 Report to Prevent Future Deaths On 8 January 2025 following the conclusion of the Inquest touching the death of Ms Sheila Ann Nicholls a Prevention of Future Deaths (“PFD”) report was issued. We respond to that report by way of this letter. To confirm, the report was shared with email and postal address was provided to Ms Mullin on 9 and 10 January 2025. on 9 January 2025 via email. ’s (1) Management and circulation of internal written policies At the time of the Inquest in October 2024, we had instructed Care4Quality (“C4Q”) to assist around our admissions process. We were considering whether or not it was practical for them to manage our suite of policies in totality. Having considered this further, we took the decision to engage C4Q to re-write all of our policies to ensure they (our new are (i) relevant (ii) specific and (iii) that we remain up to date with current legislation. Nominated Individual) is managing this process. Beginning in October 2024, C4Q now work closely with our Home Managers to review and thereafter tailor the policies to the specific requirements of our services. The process is: 1. 2. Drafting: C4Q prepare a near-final draft of the policy and send it to the Home Manager for review. Review: The Home Manager reviews the draft and provides any feedback or queries to C4Q. 3. 4. 5. Finalisation: Once all discussions have taken place, and revisions agreed upon, the policy is deemed finalised. Upload: The policy is then uploaded to C4Q’s policy platform, Astute, which our team has access to. Distribution: Our HR team then uploads the final policy to Bright HR, our HR platform. This enables direct circulation to staff. The date the policy is uploaded to Bright HR is the date the policy is deemed in force. In terms of onward monitoring and review: 6. 7. 8. 9. 10. Review: policies are reviewed yearly, or in the event of new legislation or guidelines / guidance. Acknowledgment: Bright HR generates both a “read receipt” to confirm that all staff members have read the policy and an “acceptance receipt” to confirm that all staff members have both read and accepted the contents. Communication: Any new or updated policies are discussed during the daily flash meetings, which are recorded in meeting minutes. Monitoring: Each week, the HR team meets with the Home Manager to review staff compliance data on Bright HR and follow up on any outstanding acknowledgments. Training: If additional training is required as a result of a new or updated policy, the need is identified in the weekly Manager/HR meeting, and the necessary training is then scheduled. In terms of the project’s current status: - We have 85 policies in circulation; - - - nalised; 54 are fi 17 are with the Manager for final review; and 14 are still in a drafting phase. It is envisaged all 85 policies will be in force by 30/04/2025. For the avoidance of doubt in place already are: - - - - Initial Assessment and Admissions Policy; Person-Centred Care Policy; Nutrition and Hydration (including dysphagia); and Resuscitation Policy (including choking). (2) Training in emergency response Effective from 14 October 2024, we transitioned the majority of our training to an eLearning format provided by The Access Group (Access Learning for Care). This platform automatically generates a training matrix for Mandeville Grange and also records any face-to-face sessions, ensuring the matrix remains accurate and up to date. Our HR team and the Home Manager meet weekly to review the matrix, and any face-to-face training that is due to expire within two months is immediately scheduled with one of our external trainers. To maintain consistency in our face-to-face training, we have recently engaged four additional trainers. For eLearning modules, the Access system sends automatic reminders to staff members three weeks, two weeks, and one week before their training expires. Our current training matrix indicates 100% compliance. There is some training which is scheduled to expire within one month. That training will be organised in good time. We have not carried out any emergency CPR drills to date as we have been trying to work through a process document to ensure that what we put in place is fit for purpose. The document is now finalised however the starting of drills is awaiting assessment of staff competency who will deliver the training. This will happen within 1 month. We have ordered a PractiMan Advanced CPR Adult/Child Manikin, 2-in1 Life-like CPR Training Manikin for Adult/Child CPR Training for the home. By way of additional information: left her role with Mandeville on 25 October 2024. Steps had begun to be taken to provide her with additional training and supervision, but unfortunately could not be completed before she left. (3) Investigating and learning from adverse inferences We remain committed to instructing an external person or organisation to investigate any future deaths. There has been one incident and Fulcrum Care completed a Root Cause Analysis for this. We hope the above demonstrates how seriously the concerns raised have been taken. Yours sincerely Chief Executive Officer Chiltern Care Services
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